Coronial findings and recommendations

CORONIAL LAW - Mandatory inquest pursuant to s 23(1)(d)(ii) of the Coroners Act 2009 (NSW) - First Nations death in custody- communication and treatment of family during terminal phase.

CORONIAL LAW – Group A Streptococcus pneumonia with sepsis – NSW Ambulance protocols for transportation when vital signs outside the reference range/outside the flags – point of care recognition of vital signs outside of reference range

CORONIAL LAW – cause and manner of death, cardiac arrythmia, QT prolongation, hypothyroidism, compliance with thyroxine medication, endocrine management, thyroid function test, endorsement of pathology results, multidisciplinary team meetings,

CORONIAL LAW - domestic violence - homicide - NSW Police Force - Domestic Violence Safety Assessment Tool (DVSAT) - Apprehended Domestic Violence Order - cross- agency responses to domestic violence

CORONIAL LAW - death in custody, cause and manner of death

CORONIAL LAW – missing person –overboard from boat –search –not possible to survive –

CORONIAL LAW – death as a result of police operation – First Nations man – appropriateness of police response

CORONIAL LAW – death as a result of fall from height, NSW Police operation, apprehended domestic violence order, appropriateness of NSW Police response

CORONIAL LAW – death of a person from a fall from height – did mental health services respond appropriately – are there appropriate measures for information exchange between NSW Police Force and NSW Ambulance.

CORONIAL LAW – death of person in immigration detention – self-inflicted intentional death – was mental health care adequate – were there adequate communications regarding repatriation to home country – were there adequate measures to